Orthopedic Research Articles

Between-limb Differences In Ultrasound Spatial Frequency Analysis Parameters Following Acute Hamstring Strain Injury

Treatment following hamstring strain injury (HSI) is complicated by a lack of prognostic indicators and high rates of re-injury. Spatial frequency (SF) analysis, a quantitative ultrasound method to assess structural tissue organization, could complement clinical evaluations. PURPOSE: To characterize differences in SF parameters between injured and uninjured limbs following acute HSI in Division I collegiate athletes. METHODS: Ultrasound imaging was performed within one week of HSI, also confirmed by MRI. Longitudinal B-mode images (Aixplorer, Supersonic Imagine, Aix-en-Provence, France) were acquired by a single musculoskeletal-trained sonographer using a linear array transducer (2-10 MHz) at the injury site of maximum tenderness and corresponding location for the uninjured limb. A region of interest (ROI) was drawn about the site of injury and location-matched on the images of the uninjured limb. A 2D Fourier Transform was performed on all possible 5 mm square kernels within the ROI. Peak spatial frequency radius (PSFR), a parameter corresponding to the frequency of the fascicular banding pattern, and Mmax%, a ratio comparing the prominent banded pattern relative to the background, were computed for each kernel. PSFR and Mmax% from all kernels were averaged across respective ROIs. Paired t-tests were used to compare parameter differences between limbs. RESULTS: Seven male athletes sustained HSI (mean age = 19.1 ± 0.8 yrs). PSFR (1/mm) was lower (p = 0.005) in the injured limb (0.81 ± 0.22) compared to the uninjured limb (0.95 ± 0.18). Mmax% was also lower (p = 0.023) in the injured limb (1.44 ± 0.41) compared to the uninjured limb (2.03 ± 0.56). Both measures indicated decreased tissue organization in the injured limb, characterized by disruption of the reflected fascicular banded pattern. CONCLUSION: SF analysis successfully detected differences between injured and uninjured muscle tissue. Although differences in SF parameters between limbs cannot differentiate whether alterations are due to mechanical disruption of fascicles or presence of edema, this method may have promise in identifying structural changes following HSI and in monitoring changes throughout recovery.Supported by NBA & GE Healthcare Orthopedics and Sports Medicine Collaboration and NIH Grant UL1TR002373 and TL1TR002375.

STRESS AND STRAIN DISTRIBUTION IN TEMPOROMANDIBULAR JOINT AFTER MANDIBULAR GROWTH RETARDATION: A THREE DIMENSIONAL FINITE ELEMENT STUDY

Introduction: Angle’s Class III malocclusion occurs when lower teeth occlude mesial to their normal relationship or ahead by one premolar width or even more in extreme cases. Etiology of Skeletal Class III malocclusion is considered as multifactorial because of an interaction of both hereditary (genotype) and environmental factors (phenotype). Orthopedic chin cup used in treatment of Class III malocclusion apply force on temporomandibular joint to inhibit or redirect condylar growth. The effects of an orthopedic appliance essentially depend on magnitude and direction of force. Hence, the purpose of study was to analyze and compare the stress and strain distribution in temporomandibular joint after growth retardation of the mandible by orthopedic procedure.Material and Methodology. Construction of the geometric model. b. Conversion of geometric model to finite element model. c. Material Property Data Representation. d. Defining the boundary condition. e. Application of forces. f. Evaluation of stress and strain distribution.Results & FEM study reveals changes in stress and strain generation at different anatomical locations after applying force at symphysis region. The pogonion condyle axis is key for direction of forces to induce orthopaedic effects generated by chin cup. However, in clinical situation, study can be utilized for direction planning of chin cup force with anticipated results but magnitude has to be calculated by operator withstanding in physiologic limits of patient. The orthopaedic force can be started with 300 g per side and incrementally increased according to clinical demand, physiologic limits and skeletal age of patient to avoid untoward results of orthopaedic force appliedKey words: finite element analysis, chin cup, class III, stress & strain on TMJ

3D printing of fibre-reinforced cartilaginous templates for the regeneration of osteochondral defects

Successful osteochondral defect repair requires regenerating the subchondral bone whilst simultaneously promoting the development of an overlying layer of articular cartilage that is resistant to vascularization and endochondral ossification. During skeletal development articular cartilage also functions as a surface growth plate, which postnatally is replaced by a more spatially complex bone-cartilage interface. Motivated by this developmental process, the hypothesis of this study is that bi-phasic, fibre-reinforced cartilaginous templates can regenerate both the articular cartilage and subchondral bone within osteochondral defects created in caprine joints. To engineer mechanically competent implants, we first compared a range of 3D printed fibre networks (PCL, PLA and PLGA) for their capacity to mechanically reinforce alginate hydrogels whilst simultaneously supporting mesenchymal stem cell (MSC) chondrogenesis in vitro. These mechanically reinforced, MSC-laden alginate hydrogels were then used to engineer the endochondral bone forming phase of bi-phasic osteochondral constructs, with the overlying chondral phase consisting of cartilage tissue engineered using a co-culture of infrapatellar fat pad derived stem/stromal cells (FPSCs) and chondrocytes. Following chondrogenic priming and subcutaneous implantation in nude mice, these bi-phasic cartilaginous constructs were found to support the development of vascularised endochondral bone overlaid by phenotypically stable cartilage. These fibre-reinforced, bi-phasic cartilaginous templates were then evaluated in clinically relevant, large animal (caprine) model of osteochondral defect repair. Although the quality of repair was variable from animal-to-animal, in general more hyaline-like cartilage repair was observed after 6 months in animals treated with bi-phasic constructs compared to animals treated with commercial control scaffolds. This variability in the quality of repair points to the need for further improvements in the design of 3D bioprinted implants for joint regeneration. Statement of SignificanceSuccessful osteochondral defect repair requires regenerating the subchondral bone whilst simultaneously promoting the development of an overlying layer of articular cartilage. In this study, we hypothesised that bi-phasic, fibre-reinforced cartilaginous templates could be leveraged to regenerate both the articular cartilage and subchondral bone within osteochondral defects. To this end we used 3D printed fibre networks to mechanically reinforce engineered transient cartilage, which also contained an overlying layer of phenotypically stable cartilage engineered using a co-culture of chondrocytes and stem cells. When chondrogenically primed and implanted into caprine osteochondral defects, these fibre-reinforced bi-phasic cartilaginous grafts were shown to spatially direct tissue development during joint repair. Such developmentally inspired tissue engineering strategies, enabled by advances in biofabrication and 3D printing, could form the basis of new classes of regenerative implants in orthopaedic medicine.

Involvement of FAK/P38 Signaling Pathways in Mediating the Enhanced Osteogenesis Induced by Nano-Graphene Oxide Modification on Titanium Implant Surface.

BackgroundTitanium implants are widely used in dental and orthopedic medicine. Nevertheless, there is limited osteoinductive capability of titanium leading to a poor or delayed osseointegration, which might cause the failure of the implant therapy. Therefore, appropriate modification on the titanium surface for promoting osseointegration of existing implants is still pursued.PurposeGraphene oxide (GO) is a promising candidate to perform implant surface biofunctionalization for modulating the interactions between implant surface and cells. So the objective of this study was to fabricate a bioactive GO-modified titanium implant surface with excellent osteoinductive potential and further investigate the underlying biological mechanisms.Materials and MethodsThe large particle sandblasting and acid etching (SLA, commonly used in clinical practice) surface as a control group was first developed and then the nano-GO was deposited on the SLA surface via an ultrasonic atomization spraying technique to create the SLA/GO group. Their effects on rat bone marrow mesenchymal stem cells (BMSCs) responsive behaviors were assessed in vitro, and the underlying biological mechanisms were further systematically investigated. Moreover, the osteogenesis performance in vivo was also evaluated.ResultsThe results showed that GO coating was fabricated on the titanium substrates successfully, which endowed SLA surface with the improved hydrophilicity and protein adsorption capacity. Compared with the SLA surface, the GO-modified surface favored cell adhesion and spreading, and significantly improved cell proliferation and osteogenic differentiation of BMSCs in vitro. Furthermore, the FAK/P38 signaling pathways were proven to be involved in the enhanced osteogenic differentiation of BMSCs, accompanied by the upregulated expression of focal adhesion (vinculin) on the GO coated surface. The enhanced bone regeneration ability of GO-modified implants when inserted into rat femurs was also observed and confirmed that the GO coating induced accelerated osseointegration and osteogenesis in vivo.ConclusionGO modification on titanium implant surface has potential applications for achieving rapid bone-implant integration through the mediation of FAK/P38 signaling pathways.

Propriocepção do joelho em indivíduos submetidos à menistectomia parcial e à sutura meniscal: estudo observacional

INTRODUÇÃO: Os meniscos desempenham um papel fundamental na articulação, além de gerar estabilidade e congruência articular, influenciam na propriocepção do joelho. Lesões nesta estrutura muitas vezes só podem ser reparadas cirurgicamente, pelo fraco suprimento sanguíneo local, acarretando uma regeneração insatisfatória. A hipótese desse estudo é que possa existir menores déficits proprioceptivos em pacientes submetidos à sutura meniscal quando comparados aos submetidos à menistectomia parcial, devido a conservação da estrutura que tem importância proprioceptiva. OBJETIVO: Avaliar o déficit proprioceptivo do joelho em pacientes submetidos à menistectomia parcial e à sutura meniscal. METODOLOGIA: Estudo observacional transversal realizado na clínica de ortopedia e reumatologia da UNISA, em São Paulo. Participantes foram divididos em dois grupos. No Grupo I, indivíduos submetidos à menistectomia parcial, enquanto no Grupo II, a submetidos à sutura meniscal, sendo recrutados indivíduos de até 4 semanas de pós-operatório. Aprovado pelo comitê de ética seguido pelo CAAE 94144218.0.0000.0081. Para coleta dos dados foram realizados três testes: teste de senso de posicionamento ativo e passivo e teste de cinestesia. RESULTADOS: Participaram deste estudo uma amostra por conveniência de oito indivíduos (Grupo I, n=4 e Grupo 2, n=4), de ambos os gêneros, com média de idade de 33,4 anos (±11 anos). Os sujeitos do grupo I apresentaram maior déficit de proprioceptivo em comparação com o grupo II, nos testes realizados. Teste ativo do grupo I: 15°= 11,9° ±6,1; 30°= 11,6° ±5,0; 45°= 9,4° ±3,5 e do grupo II, 15°= 7,6° ±3,9; 30°= 6,9° ±2,8. Teste de Cinestesia: Grupo I 132ms ±51,5 vs Grupo II 96ms ±28,8). CONCLUSÃO: Os meniscos demonstraram ser estruturas influentes para a propriocepção do joelho, apresentando maiores déficits em indivíduos que retiraram a estrutura.

Procedures and strategies for sterilization and management of surgical instruments for patients with orthopaedic trauma during COVID-19 epidemic

Procedures and strategies for sterilization and management of surgical instruments for patients with orthopaedic trauma during COVID-19 epidemic

Risk assessment of mixed and displacement ventilation (LAF) during orthopedic and trauma surgery on COVID-19 patients with increased release of infectious aerosols.

No abstract available Keywords: Displacement ventilation; SARS-CoV-2 spread; laminar air flow; mixed ventilation; negative pressure; no ventilation.

Corrigendum to "The Motoric Types of Delirium and Estimated Blood Loss during Perioperative Period in Orthopedic Elderly Patients".

[This corrects the article DOI: 10.1155/2018/9812041.].

Anticoagulation Strategies for the Orthopaedic Surgeon: Reversal and Timelines.

Article Highlights: 1) This article provides a full anticoagulant reference for the practicing orthopaedic surgeon which can be used in any clinical scenario, whether urgent or elective surgical intervention is required 2) A comprehensive list of anticoagulant reversal agents and drugs with short half-lives (for bridging) are described with the intention to provide the data needed to safely manage a patient peri-operatively during urgent orthopaedic surgical care (i.e. fracture or infection) 3) Half-life and method of excretion for all drugs are included with the intention to accurately guide decisions regarding the appropriate timing of scheduling elective orthopaedic surgical care with regards to anticoagulant metabolism and effect 4) The practicing orthopaedic surgeon using this guide should always consider medical co-management of these complex patients as their medical co-morbidities may not be amenable to anticoagulant reversal or peri-operative cessation of therapy, even for a short period 5) The data contained in this article stands to serve as a foundation upon which institution-specific guidelines regarding the peri-operative management of orthopedic patients on long-term anticoagulation can be developed

Malpractice Litigation for Compartment Syndrome

The aim of this study was to analyze litigation involving compartment syndrome to identify the causes and outcomes of such malpractice suits. A better understanding of such litigation may provide insight into areas where clinicians may make improvements in the delivery of care. Jury verdict reviews from the Westlaw database from January 1, 2010 to January 1, 2018 were reviewed. The search term "compartment syndrome" was used to identify cases and extract data on the specialty of the physician defendant, the demographics of the plaintiff, the allegation, and the verdict. A total of 124 individual cases involving the diagnosis of compartment syndrome were identified. Medical centers or the hospital was included as a defendant in 51.6% of cases. The most frequent physician defendants were orthopedic surgeons (45.96%) and emergency medicine physicians (20.16%), followed by cardiothoracic/vascular surgeons (16.93%). Failure to diagnose was the most frequently cited claim (71.8% of cases). Most plaintiffs were men, with a mean age of 36.7years, suffering injuries for an average of 5years before their verdict. Traumatic compartment syndrome of the lower extremity causing nerve damage was the most common complication attributed to failure to diagnose, leading to litigation. Forty cases (32.25%) were found for the plaintiff or settled, with an average award of $1,553,993.66. Our study offers a brief overview of the most common defendants, plaintiffs, and injuries involved in legal disputes involving compartment syndrome. Orthopedic surgeons were most commonly named; however, vascular surgeons may also be involved in these cases because of the large number of cases with associated arterial involvement. A significant percentage of cases were plaintiff verdicts or settled cases. Failure to diagnosis or delay in treatment was the most common causes of malpractice litigation. Compartment syndrome is a clinical diagnosis and requires a high level of suspicion for a timely diagnosis. Lack of objective criteria for diagnosis increases the chances of medical errors and makes it an area vulnerable to litigation.

Stem Cells: A Reformist Therapeutic Approach to Orthopaedic Sports Medicine

Background: The aim of the research is to identify, study the effects of stem cell therapies on sports injuries and examine how stem cell therapies may benefit the healing process and improve the athletes' physical state. With an extensive literature review, the purpose of this article to investigate the true potentials of regenerative stem cell therapy and shed light on innovative ways of treatment for sports injuries. It is theorized that stem cell therapy is an efficient and effective treatment method for sports injuries. Stem cell therapy is an innovative way of treating musculoskeletal injuries to provide faster and safer treatment to athletes. As sports injuries are one of the major concerns of the athletes, stem cell therapies are quite promising with effective and safe results. It is possible to fully heal certain injuries, regain functions, and reduce symptoms. Stem cell therapy is a method that should be popularised and preferred particularly by athletes.

The state of integration of ukrainian orthopedic studies in the world science

The involvement of Ukrainian clinical scientists in the field of orthopedics and traumatology in world of medicine is an urgent problem, as evidenced by the level of reflection of domestic research in international specialized publications. Objective: to determine the features of scientific activity of Ukrainian orthopedic and traumatology surgeons based on the analysis of quantitative indicators as Scimago Journal & Country Rank, Scopus and Web of Science.Methods: the Hirsch index (h-index, Scopus) of 92 doctors of medical sciences in the specialty «Traumatology and Orthopedics», selected from the «Scientists of Ukraine» database (V. I. Vernadsky National Library), was evaluated. The number of publications of these researchers in foreign journals in general (according to the Scimago Journal & Country Rank) was analyzed. We also estimated the dependence on the quartile of the journal (Web of Science) in the specialty Orthopedics and Sports Medicine from 2014 to 2018.Results: for the studied period of time (2017–2018), the publication activity of Ukrainian doctors was increased in the specialty Orthopedics and Sports Medicine. So, in 2017, Ukraine took the 69th place (Scimago Journal & Country Rank) in terms of the number of publications in the ranking of countries of the world, and in 2018 — already 62nd. More than half of the identified works were published in the journals of the fourth quartile, and only a quarter of the first. The citation index of the most orthopedic traumatology surgeons remains low, which can be explained by the choice of a journal for publication with a low impact factor or a small number of published works indexed by Scopus and Web of Science.Conclusions: it is necessary to introduce Evidence-based medicine research standards into everyday practice. This determines the importance of teaching our native scientists how to plan and conduct research study, analyze and prepare for printing the results.

Clinical application of the concept of enhanced recovery after surgery in perioperative nursing of patients with total hip replacement

Objective To explore the clinical effect of the concept of enhanced recovery after surgery (ERAS) in the perioperative nursing of patients with total hip replacement. Methods A total of 93 patients with hip osteoarthritis admitted from June 2017 to June 2018 were divided into routine nursing group and ERAS nursing group according to the random number table method. Patients in both groups were treated with unilateral total hip arthroplasty. Routine nursing group was treated with routine perioperative nursing, and ERAS nursing group was treated with ERAS concept. The ERAS nursing team was established, including a head nurse and an orthopedic physician, in addition to the regular nursing staff. The treatment, perioperative pain and nursing satisfaction of the two groups were compared. Results The first time of getting out of bed activity [(1.95 ± 0.45) days vs. (5.52 ± 2.52) days], the first time of defecation after operation [(1.34 ± 0.56) days vs. (2.15 ± 0.84) days], the time of hospitalization [(5.73 ± 1.65) days vs. (10.04 ± 2.14) days] in ERAS nursing group were shorter than those in routine nursing group, and the cost of hospitalization [(49 450.50 ± 880.52) yuan vs. (53 053.50 ± 780.50) yuan] was lower than that in routine nursing group, the differences were statistically significant (t=6.639-31.622, P < 0.05). The NRS scores of 24 hours [(3.35 ± 0.85) vs. (4.32 ± 1.05)], 48 hours [(2.65 ± 0.52) vs. (3.48 ± 0.54)] after operation and discharge [(1.74 ± 0.65) vs. (2.36 ± 0.53)] in the ERAS nursing group were lower than those of the routine nursing group, the differences were statistically significant (t=4.526, 4.856 and 4.456, P < 0.05). The nursing satisfaction rate of ERAS nursing group (95.7%, 45/47) was higher than that of routine nursing group (76.60%, 36/47), the difference was statistically significant (P<0.05). Conclusion The idea of ERAS has a good clinical effect in perioperative nursing of patients with total hip replacement. Key words: Enhanced recovery after surgery; Hip osteoarthritis; Hip replacement; Perioperative nursing

The clinical effect of flavored qufusheng muscle paste combined with moxibustion with moxa stick in the treatment of stage III and IV pressure sores and its effect on the healing time of pressure sores

Objective To explore the clinical effect of flavored qufusheng muscle paste combined with moxibustion with moxa stick in the treatment of stage Ⅲ and Ⅳ pressure sores and its effect on the healing time of pressure sores. Methods A total of 64 patients with stage Ⅲ and stage Ⅳ pressure ulcers admitted to the rehabilitation, orthopedic and encephalopathy departments of Baoan Hospital of Traditional Chinese Medicine from January 2019 to June 2020 who met the inclusion criteria were selected as the experimental subjects, and were randomly divided into experimental group and control group using the number table method, 32 cases of each group. The control group was treated with conventional debridement treatment, antibacterial dressing packing, alginate packing and dressing changing, etc. On this basis, the experimental group was given the patients with flavored qufusheng muscle paste external application combined with moxibustion treatment. The growth time of skin granulation tissue, the healing time of pressure ulcer wound, the curative effect and the quality of life were observed. Results The total effective rate of the experimental group was significantly higher than that of the control group, and the difference was statistically significant(P<0.05). The growth time of skin granulation tissue and wound healing time of the experimental group were significantly shorter than those of the control group, and the difference was statistically significant(P<0.05). The GQOL-74 quality of life score of the experimental group was significantly higher than that of the control group, and the difference was statistically significant(P<0.05). Conclusions Flavored remove metatrophic ointment topical joint moxa roll maneuver, moxibustion therapy Ⅲ and Ⅳ period of pressure ulcers in, effectively shorten the patient wound healing time and granulation tissue growth time, improve the quality of life, great application value. Key words: Stage Ⅲ and Ⅳ pressure sores; Moxa twirl moxibustion; Flavored qufusheng muscle paste; Curative effect; The quality of life

Phylogenetic analysis of the complete chloroplast genome of Prunus persica seed as the Chinese herbal medicine to China

The seed of Prunus persica is a kind of commonly used Chinese herbal medicine in orthopedics at China. In this study, we assembled and annotated the complete chloroplast genome of P. persica. The chloroplast genome size was 157,704 bp as a circle, which contained a large single-copy region (LSC, 85,883 bp), a small single-copy region (SSC, 19,061 bp) and a pair of inverted repeat regions (IR, 26,380 bp). The overall nucleotide composition is: 31.1% of A (49,092 bp), 32.1% T (50,709 bp), 18.8% C (29,625 bp) and 18.0% G (28,278 bp), with a total G + C content of the chloroplast genome 36.8% and A + T of 63.2%. The chloroplast genome of P. persica contains 123 genes, which included 78 protein-coding genes (PCG), 37 transfer RNA (tRNAs) and 8 ribosome RNA (rRNAs). Furthermore, the phylogenetic analysis based on 14 plants species confirmed the position of P. persica closely related to Prunus mongolica.

Analysis of anxiety, depression and related factors in patients with chronic lumbocrural pain before minimally invasive surgery

To investigate anxiety and/or depression status of patients with chronic lumbocrural pain, and to further analyze related risk factors of anxiety and/or depression . Retrospective analysis of the medical data of patients who suffered from chronic lumbocrural pain caused by lumbar disc herniation and/or lumbar spinal stenosis and received minimally invasive surgery from March 2018 to April 2018. General data (including age, gender, education levels, past history, sleep order and medical insurance), numeric rating scale(NRS), Japanese Orthopedic Association(JOA) back pain scale and hospital anxiety and depression scale(HADS) were collected for analysis. The basic demographic data and clinic data were analyzed, possible related risk factors associated were analyzed by univariate analysis, and multivariate Logistic regression analysis was further used to find the relative independent risk factors and included all the predictive variables with P values less than 0.05 as covariates. A total of 91 patients met the inclusion criteria and finished this study, the mean HADS score for anxiety was 8.1±4.2, 48(52.7%) respondents were screened positive for anxiety, while the rest 43(47.3%) patients had negative anxiety state, the mean HDDS score for depression was 6.9±4.9, 38(41.8%) respondents were screened positive for depression, and the rest 53(58.2%) patients were not depressed, and 56(61.5%) patients experienced anxiety or depression. There were significant difference in sleep disorder, JOA score and leg NRS score between the patients with and without anxiety(P<0.05), and the significant differences were also found in age, sleep disorder and JOA score between the patients with and without depression(P<0.05), Logistic regression analysis further showed that the JOA score and sleep disorder were risk factors for anxiety, and the JOA score was risk factor for depression. Patients with chronic lumbocrural pain are often accompanied by anxiety and/or depression before minimally surgery, the low JOA score and sleep disturbance increased the risk of presenting anxiety, and the low JOA score increased the risk of developing depression. It is necessary to evaluate mental status and related risk factors before surgery.

WhatsApp in mHealth: an overview on the potentialities and the opportunities in medical imaging.

WhatsApp as many other Messaging Apps or "Messengers" enables messaging and exchanging documents and/or multimedia element (images, movies, music) through chat like tools; these last characteristics makes WhatsApp useful for the remote-image exchanging in mHealth for teleconsulting. Among the other potentialities of this App there are (I) the possibility to create groups, the so called WhatsApp Groups and (II) the possibility of this App to be installed into a platform based on a personal computer through the version for pc named WhatsApp Web; these potentialities allow both the creation of protected groups for cooperative teleconsulting and the creation of client-server architectures in telemedicine and e-Health. Scholars have recently shown the usefulness of WhatsApp in several mHealth applications. Recent important studies are highlighting, for example, the wide-range opportunities of WhatsApp as an adjunctive tool in mHealth in medical imaging or in specific applications such as in oral medicine in orthopedics and tele-education. In this contribution we share our alignment with these scholars and presents our polarities of research in the use of WhatsApp. These polarities range from the institutional surveillance of the spontaneous phenomena of WhatsApp groups in the families for the monitoring of the fragile patient up to the test of use of WhatsApp in digital-pathology and digital-radiology static imaging and recently in cardiologic dynamic imaging.

PEDIATRIC ORTHOPEDIC RADIOGRAPH REDUCTION: A QUALITY IMPROVEMENT INITIATIVE

Background:Children are more vulnerable to ionizing radiation which increases health risks later in life including cancer. An interdepartmental team developed an algorithm to guide providers ordering extremity radiographs in pediatric patients with musculoskeletal (MSK) injuries.Purpose:Reduce unnecessary pediatric radiation/extremity radiographs through development and implementation of an interdepartmental designed algorithm. Determine utility, safety, and efficacy of the algorithm through retrospective and prospective analysis.Methods:Our study was performed at an academic pediatric trauma center. An interdepartmental committee including pediatric orthopedic surgery, emergency medicine, trauma, and radiology providers created a MSK injury imaging algorithm (Figure 1). We retrospectively validated the algorithm for efficacy and safety through chart review of pediatric patients seen in the ED with MSK extremity injury, identified through CPT code, from 6/24/2016 through 8/31/2016. We determined the number of extra radiographs per patient and identified if injuries would be missed utilizing our protocol. After retrospective validation, guideline implementation was undertaken through multidisciplinary education. The imaging guideline was prospectively implemented in the pediatric ED from 6/24/2018 through 8/31/2018. We continued to prospectively evaluate through selecting one week every month over the following eight months to determine sustainability of the implemented algorithm.Results:Our interdepartmental team in 2016 developed a pediatric MSK radiograph protocol (Figure 1). A retrospective chart and radiograph review of 295 pediatric patients between 6/24/2016 through 8/31/2016 was analyzed correlating physical examination to appropriate radiographs. Utilizing the protocol, the review revealed an average of 2.75 extra radiographs per patient. No injuries were missed. Providers including orthopedic and emergency medicine attendings, mid-levels, and residents were educated through meetings, emails, and having the protocol posted and easily accessible. Our protocol was implemented 6/24/18 and underwent prospective enrollment and review through 8/31/18 which revealed a reduction to 0.72 radiographs per patient (P-value <0.001) (Figure 2). Eight month follow up revealed a sustainable reduction in extra radiographs per patient (Figure 3).Conclusion:Reduction of unnecessary radiation to pediatric patients with MSK extremity injuries was accomplished through development and implementation of a safe and effective imaging algorithm. The multidisciplinary approach combined with widespread education of pediatric providers improved buy-in driving a sustainable system improvement.Figure 1.Pediatric Extremity Injury AlgorithmFigure 2.Average number of radiographs per pediatric patient not indicated by imaging algorithms before and after protocol implementation. (P<0.001)Figure 3.Eight month follow up of average number of extra radiographs per patient

PAST, CURRENT AND FUTURE INTERVENTIONAL ORTHOBIOLOGICS TECHNIQUES AND HOW THEY RELATE TO REGENERATIVE REHABILITATION: A CLINICAL COMMENTARY

5.

Venous Thromboembolism Prophylaxis After “Nonmajor” Lower-Limb Orthopedic Procedures

Whether prophylaxis against venous thromboembolism (VTE) is warranted after so-called nonmajor lower-limb orthopedic procedures is controversial. In